1Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
Secretaría de Programas Sanitarios
Provincial Maternal -Child Health Investment
Project
Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF)
workshop
2Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
• Plan Nacer in the Argentinean Health System• Final outcomes targeted
3Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
Plan Nacer Argentina
Plan Nacer Argentina
(0,1][0,0]
1st Phase since 20052nd Phase since late 2007
4Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
Argentina's health system organization
* Estimates based on Permanent Household Survey (PHS) - INDEC
Structure of Argentine's Health System in 2008 *The Health Coverge is organized in 3 Sub-System
20,949,902
3,843,663
14,592,048
39,745,613
-
5
10
15
20
25
30
35
40
45
Social Security Private Sector Public Sector Budget Total
Popu
latio
n in
Mill
ons
52.71%
9.67%
37.62%
100%
5Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
Plan Nacer’s Share
In Population Terms
14,952,048
2,072,601
0 2 4 6 8 10 12 14 16Population in Millons
13.86%Plan Nacer
Public Sector Budget
2006/ 7 - In Expenditures Terms (mill u$s)
572
32,8
2938
0 500 1000 1500 2000 2500 3000Millons usd
5,7%
All Provincies
NE & NW
Plan Nacer
Target Population: Children under six and pregnant women, until the 45th day after delivery, who don’t have health insurance (other than the public sector budget)
6Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
Final outcomes being targeted
Contribution to the reduction of inequality in health outcomes
Contribution to the The Millennium Development Goals Evolution of infant mortality rates in Argentina
Expressed as a rate per 1,000 live birthsEvolution of Infant Mortality Gini Coefficient
Argentina 1990-2006
0.100
0.122
0.104
0.124
0.130
0.118
0.075
0.117
0.106
0.060
0.070
0.080
0.090
0.100
0.110
0.120
0.130
0.140
1990 1995 2000 2001 2002 2003 2004 2005 2006
Infa
nt M
orta
lity
Gin
i Coe
ffici
ent
25.6
22.2
16.6 16.3 16.8 16.5
14.413.3 12.9
5
10
15
20
25
30
1990 1995 2000 2001 2002 2003 2004 2005 2006
Infa
nt M
orta
lity
rate
7Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
The National Government have embarked on a new kind of relationship with the Provinces to coordinate efforts in health provision
To strengthen the Public Health Subsystem in particular the Primary Healthcare Network
To increase accessibility and improve quality of health care (effective coverage)
To Contribute to the reduction of maternal and infant morbimortality rates
Plan Nacer´s Main Goals
8Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
Coverage Rate Evolution by Region NE and NW Regions
NE; August-08: 81%248.515 Beneficiaries
NW; August-08: 77%275.644 Beneficiaries
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
April
- 05
Aug -
05
Dec -
05
April
- 06
Aug -
06
Dec -
06
April
- 07
Aug
-07
Dec -
07
Jan -
08
Feb-
08
Mar-0
8
April
-08
May-0
8
Jun-
08
Jul-0
8
Aug -
08
Sep -
08*
Oct-0
8*
Nov-0
8*
Dec-0
8*
NE NW APL1
PROVINCIAL GOAL OBSERVED DATA
Dec-2008* 89%Beneficiaries Target NE 274.380 NW 321.271 Total 595.651
Total August-08: 79%524.159 Beneficiaries
9Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
Beneficiaries by region / Investment :
PATAGONIA29.680 Sept ´08
76.035 Target
Total Investment
1st Phase USD 135.8 MM (70% used) since 2005
2nd Phase USD 300 MM (5% used) since late 2007
Total Beneficiaries 897.219 - Sept-091.4 MM have been enrolled in the Plan Nacer
since de begining of de Program
CENTRO269.657 Sept ´08
1.053.288 Target
CUYO73.974 Sept ´08
188.660 Target
NOA274.253 Sept ´08
359.189 Target
NEA249.655 Sept ´08
307.455 Target
10Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
Health Providers by Region– August 2008
PATAGONIA353
Total Providers with Agreement
4.061
CENTRO1.351
CUYO490
NOA1.054
NEA813
11Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
Principal – Agent Framework Main Actors of the strategy
PROVINCES SERVICE PROVIDERS
Maternal-Child insurance Unit Primary Health Care Centers and Maternity Hospitals
ENROLLMENT Final Validation of Beneficiaries databases
Identification and enrollment of eligible population
Enrollment and follow up beneficiaries
NOMENCLATURE Design and definition of a package of basic healthcare practices
Define the pricing policy for a group of basic practices
Provision and billing of health care services
Provide Financial Resources: Use of funds in:g Human resourcesg Equipmentg Infrastructureg Inputs
Supervision and Monitoring of: g Beneficiaries Database Services renderedg Tracers Tracersg Services rendered
Hiring and payment of services covered
Unique bank account managementPAYMENT
MECHANISMS
AUDITING Medical history registration
Mana
gem
ent c
omm
itmen
t - L
egal
Fra
mew
ork
Agre
emen
t - L
egal
Fra
mew
ork
NATIONAL GOVERNMENT
• 60% linked to the identification and registration of eligible population
(enrollment)
• 40% linked to the fulfillment of specific health goals (tracers) -
Includes setting of healthcare goals through mother-child indicators
Roles \ Actors
12Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
Plan Nacer’s Payment Mechanism
National Level
Provincial Level
Target Population
Providers
Capitation split in 2 Result Based-Financing
(RBF)
Fee for Service
Use of nomenclature (Primary Health care
Practices)
60% Enrollment
40% HealthOutcomes(Tracers)
Change in health outcomes
13Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
Principal-Agent Relationships with asymmetric information predicts opportunistic behavior
NATION (PRINCIPAL) - PROVINCE (AGENT)
PROVINCIAL LEVEL OPPORTUNISM
Funding crowding out of spending Pre contract opportunism (hiding information when defining targets) Post contact opportunism (shirking effort & hiding information to
avoid higher targets in future periods)
PROVINCE (PRINCIPAL) - HEALTH PROVIDER (AGENT)
HEALTH PROVIDER LEVEL OPPORTUNISM
Misuse of practices Overbilling of high prices practices (delivery) Potential fraudulent overbilling
Theoretical Framework
14Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
Principal-Agent Relationships with asymmetric information predicts opportunistic behavior
PROJECT RESPONSES
Change in the results’ payment scheme
Stakeholder approach to monitor and put credible monitoring threats (coordinate different principals guide in the provider’s effort), it includes beneficiaries empowerment: Social Control
Monetary sanctions firmly applied
Strengthening and directing Auditing Activities (External Concurrent Auditing and Internal Auditing and Supervision, National and provincial level auditing organisms)
Theoretical Framework
15Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
Change in the incentives’payment scheme
Incentives payment function
From: All-or-nothing
To: Flexible or continuous
(3 thresholds scheme)
0%
1%
2%
3%
4%
5%
LS ij
% Trans. Mensual Base
Thresholds rule has better incentive properties in terms of avoiding opportunistic behavior
0%
1%
2%
3%
4%
0 1 CAij/ Dij
% Trans. Mensual Base
16Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
The need to define a model for institutional change
Resources
Policy Consensus
Conflict Zone
Result Based-Management
Steering Role
17Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
Bureaucratic Model New Model in Public Management
Rule fulfilment
Central Intervention
Focus on implementation
Focus on formal fulfilment
Closed information system
Incentives
Decentralized responsibility
Focus on impact
Focus on user performance and satisfaction
Transparency and Social Oversight
Focus on inputs Focus on the Performance
New Paradigm in Public Management
18Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
Specific Health Goals: Plan Nacer Tracers
N° HEALTH GOALS DESCRIPTION
I Early detection of pregnant women Detection before the 20th week of pregnancy
II Effectiveness of childbirth and neo-natal care Newborn's physical condition after delivery (APGAR - Appearance, Pulse, Grimace, Activity, Respiration- score > 6 at 5 minutes after birth )
III Effectiveness of prenatal care and prevention of pre-maturity Infants weighing more than 2500 g
IV Effectiveness of prenatal care and childbirth care VDRL -Venereal Disease Research Laboratory- test and immunization for mothers against tetanus
V Audit of mother and child deaths Audit process in case of mother or child death seeks to evaluate and improve the current level of care
VI Immunization coverage Triple viral and measles immunization for children under 18 moths
VII Sexual and reproductive care Provision of information on contraceptive and sexual health services during puerperium
VIII Follow-up of healthy children up to one year old Provision of health care and checkups for children up to one year old
IX Follow-up of healthy children from 1 to 6 years of age Provision of health care and checkups for 1 to 6 year old children
X Inclusion of indigenous communities Health care provision for indigenous population
19Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
Funds Transfers – August 2008
Total Transfers 1st Phase since 2005USD 60,261,148
Total Transfers 2nd Phase since late 2007USD 11,994,026NEA
USD 28,839,214
NOAUSD 31,421,935
CUYOUSD 2,714,473
PATAGONIA USD 811,873
CENTROUSD 8,417,679
20Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
Nomenclature’s Practices
g Health Education Consultation during pregnancyg Papanicolau and Colposcopyg Antitetanic Vaccine g High-risk Pregnancy consultationg Human immunodeficiency virus (HIV) care during pregnancy g Deliveryg Cesareang Measles immunizationg Puerperium counseling g Immunization of the new-born childreng Incubator up for a period of 48 hoursg Immediate treatment in case of HIV vertical transmission g Ophthalmologic consultationg Follow-up consultationg Dental care counselingg Pregnancy testg Colposcopy in pregnant controlg Blood extractiong Blood testg Thoracic XRg Ecographyg Detection of pregnant women in their first quarter of pregnancy by sanitary or health care agents g Round of sanitary agent in rural area g Socio – Epidemiologic diagnosis of population at risk g Reunions for feeding guidelines promotion g Infant development promotion meetings g Newborn emergency transportation serviceTransport
Children
GROUP AND SUBGROUP
Woman
EXAMPLE PRACTICES
Community
Images
Laboratory
Pregnant Woman
High risk Pregnancy
Delivery
Puerperium
Neonate
Infants under 6 years old
21Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
Nomenclature’s Practices
GROUP AND SUBGROUP1st Phase
Practices Amount
Woman
Pregnant Woman 6,5% 5,4%High risk Pregnancy 0,4% 0,7%Delivery 1,7% 30,2%Puerperium 2,5% 2,3%
ChildrenNeonate 1,1% 1,9%Infants under 6 years old 49,8% 46,1%
Laboratory 11,9% 4,6%Images 2,1% 2,4%Community 8,4% 4,5%Transport 15,6% 2,0%TOTAL 100,0% 100,0%
Group and Subgroup practices: Percentage Structure August- 2008
22Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
Inscription Monitoring by Province DepartmentsProvince: Misiones
Inscription Coverage Rate ranged by Infant Mortality Rate August 2008
88%
64%
94%
77%82% 84%
94%
75%
89%
95%90%
86%90%
93%88%
98%
87%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
San
Javie
r
Conc
epció
n
Mont
ecar
lo
Lean
dro
N. A
lem
Ober
á
Iguaz
ú
Guar
aní
Após
toles
San
Ignac
io
Cand
elaria
Caing
uás
Gene
ral M
anue
lBe
lgran
o
25 d
e Ma
yo
San
Pedr
o
Liber
tado
r Grl.
San
Martí
n
Capit
al
Eldor
ado
Range 5,4 - 12,9 Range 13,4 - 16,8 Range 18,1 - 26,6Source: DEIS 2006
23Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
Tracer I Evolution: Early Detection of Pregnant Women
Evolution Tracer I: Early Detection of Pregnant womenNE - NW - 1 st Phase
5,7% 4,5%
11,4%
35,9%
49,9%
23,4%
38,0%
19,1%
44,2%
53,3%57,9%
37,2%
4,0% 4,6%7,0%
13,9%
23,5%
27,1%
39,9%
45,9%
53,7% 54,7%
4,7%
23,6%
36,5%
2,3% 3,0%
8,9%
19,3%
36,0%
42,3%
54,1%
51,9%
0%
20%
40%
60%
80%
100%
II-2005 III-2005 I-2006 II-2006 III-2006 I-2007 II-2007 III-2007 I-2008 II-2008 III-2008*
Average NE Average 1 st Phase Average NWIII - 2008*: Projection
24Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
Tracer II Evolution: Effectivenss of Childbirth and Neo Natal Care
Evolution Tracer II: Effectiveness of Childbirth and Neo - Natal CareNE - NW – 1st Phase
24,0%25,3%
4,6%
39,4%
15,0%
48,8%
72,5%69,2% 66,5%
90,8%87,7%
20,3%
30,5%
8,5%
36,5%
89,0%
71,9%
98,9%
87,8%
70,5%
50,9%
69,8%
12,2%
36,6%
97,2%97,2%
87,9%
33,7%
52,8%
68,8%
74,3% 72,8%
0%
20%
40%
60%
80%
100%
II-2005 III-2005 I-2006 II-2006 III-2006 I-2007 II-2007 III-2007 I-2008 II-2008 III-2008*Average NE Average 1 st Phase Average NWIII - 2008*: Projection
25Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
Tracers Monitoring by Province DepartmentsProvince: Córdoba
Tracers Analysis by Department(Every four months)
Tracers I, II, III, IV are related with pregnancy and delivery
I By Dep II By Dep III By Dep IV By DepCalamuchita 8 1,6% 58 1,5% 58 1,6% 29 1,0%Capital 80 15,8% 1530 40,9% 1389 39,3% 1341 46,9%Colón 36 7,1% 187 5,0% 184 5,2% 118 4,1%Cruz del Eje 43 8,5% 198 5,3% 191 5,4% 183 6,4%General Roca 3 0,6% 19 0,5% 21 0,6% 18 0,6%General San Martín 32 6,3% 185 4,9% 168 4,8% 86 3,0%Ischilín 6 1,2% 44 1,2% 43 1,2% 5 0,2%Juárez Celman 8 1,6% 37 1,0% 41 1,2% 36 1,3%Marcos Juárez 7 1,4% 26 0,7% 24 0,7% 13 0,5%Minas 1 0,2% 2 0,1% 2 0,1% 1 0,0%Pocho 0 0,0% 0 0,0% 0 0,0% 0 0,0%
Pte. Roque Sáenz Peña 4 0,8% 41 1,1% 41 1,2% 4 0,1%Punilla 71 14,0% 269 7,2% 254 7,2% 162 5,7%Río Cuarto 38 7,5% 512 13,7% 474 13,4% 479 16,7%Río Primero 13 2,6% 5 0,1% 10 0,3% 2 0,1%Río Seco 0 0,0% 0 0,0% 0 0,0% 0 0,0%Río Segundo 14 2,8% 33 0,9% 32 0,9% 27 0,9%San Alberto 6 1,2% 15 0,4% 14 0,4% 13 0,5%San Javier 9 1,8% 114 3,0% 112 3,2% 95 3,3%San Justo 42 8,3% 158 4,2% 172 4,9% 139 4,9%Santa María 10 2,0% 136 3,6% 128 3,6% 4 0,1%Sobremonte 7 1,4% 0 0,0% 1 0,0% 1 0,0%Tercero Arriba 4 0,8% 60 1,6% 63 1,8% 0 0,0%Totoral 6 1,2% 0 0,0% 0 0,0% 0 0,0%Tulumba 2 0,4% 1 0,0% 1 0,0% 1 0,0%Unión 57 11,2% 115 3,1% 111 3,1% 103 3,6%Sin Especificar 0 0,0% 0 0,0% 0 0,0% 0 0,0%
Total Córdoba 507 100,0% 3.745 100,0% 3.534 100,0% 2.860 100,0%
DepartmentTracers I four month period-2008
26Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
Use of Funds Monitoring by Province Province: Corrientes
Use of Funds by Providers - 1st PhaseAmount of funds spent up to June 2008 : USD 28,401,147.35
Maintenance and Investment
30,5%
Medical Inputs7,2%
Professional Services24,7%
Others11,7%
Incentives25,9%
27Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
A change in payment mechanism is mainly a change in the way the different actors relate with each other in a public policy
This may bring important changes in how to achieve health outcomes
In this change data accuracy play an important role
Uncertainty and asymmetric information is the natural context we must deal with.
Main Lessons
28Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
To encourage health teams to provide integral health care coverage
Strengthening decentralized monitoring capabilities and steering role of the provinces
Generalize the payment mechanism in terms of expenditures in the public health system
The national goverment decided to include a high complexity practice in the Plan Nacer Nomenclature: Congenital Heart Disease Surgery
Challenges
29Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
Plan Nacer Impact Evaluation. Main Objectives
1. To measure the change in the Health Care Facilities’ behavior that provide Primary Health Care to eligible population when facing the new payment strategy introduced by the Plan Nacer.
2. To measure the impact in coverage and quality of the health care services provided to pregnant women and children under 6 yeas of age
3. To measure the change in Health outputs and outcomes in pregnant women and children under 6 yeas of age as a result of the introduction of the program
30Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
2005 2006 2007 2008 Dec 2008
1st Method: a Household
Survey
3 Party TEAM …P.NACER+WB+CEO
P:1st STRATEGY
Jun 05
Baseline 1st Phase
Oct 06 Feb 07
Feb 06
Oct 07
New Strategy to measure causality:
Instrumental variables – Pilot
Survey
Baseline 2nd Phase
I.E.
Plan Nacer
Provinces start to Enroll
Jun 05
All Provinces are included -
Provinces start to Enroll
Jun 07
Provinces start Payment
Mechanism
Plan Nacer and itsImpact Evaluation Strategy in time
Payment mechanisms start
in 2nd Phase
31Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
Time line of the impact evaluation
We plan 3 moments in the evaluation process:
1. Moment 0 Corresponds to the baseline measurement
2. Moment 1 To measure the intermediate impacts of the program (scheduled for 2009/2010)
3. Moment 2 To measure the final impacts of the program (scheduled for 2011/2012)
32Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
Specific objectives
1. Sampling design and selection of providers and eligible population in their catchment area (in the provinces adherent to the Plan Nacer).
2. Sampling design and selection of a control group
3. Design of questionnaires to gather data
4. Data gathering at households, health facilities, medical records and specific measures of anemia, height and weight
5. Data base organization of the collected data to permit the follow up of treatment and control groups
33Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
Sampling technique
• Representative at provincial level Both
requirements were fulfilled
• Sample power to capture change
• A multi-stage stratified sampling procedure was implemented to select localities, then providers and finally the eligible population in their catchment area
34Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
Propensity score matching between localities in provinces of the 1st Pahse and localities in sorrounding provincies : • Dependent variable: Y=1, treatment; Y = 0, not treatmet
• We used available data at locality and facility levels as indipendent variables (sources: Population Census 2001 and Remediar Plan providers` list. Both constitute the sampling frame).
• A probability (p) was estimated to pair localities.
Locallities were paired and we had a balanced treatment and control groups
Statistical tests were applied to evaluate the sample power
A first attempt to capture causality in 1st Phase
35Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
A first attempt to capture causality in 1st Phase
• Multi-stage sampling and Propensity Score Matching allowed to select the localities’ sample
• Within the localities sample a providers’ sample was selected (60 providers in each province)
• For each provider a sample of 10 households was selected (eligible population with the latest child born in the previous 13 months
36Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
Difference in differences
• We planned a panel survey in moments 1 and 2 to obtain a difference in difference estimates of the change in main output and outcome indicators using a regression equation like the following one:
y = 0 + 1d + 2t + 3(dt) + X + v
Where:• Y: is an output or outcome variable • d: is 1 if the person is a beneficiary of the program and 0 if the
person belongs to the control group• t: is 1 in moments 1 or 2 and 0 in the baseline• dt: is 1 if the person is beneficiary in moments 1 or 2 and 0 in
other cases• X: Vector of variables that affect and• v: random variable.
37Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
Sample Sizes
Planned Sample Sizes in Plan Nacer´s Impact Evaluation
PER PROVINCE TOTAL PER
PROVINCE TOTAL
PHASE 1 9 167 60 540 600 5,400
PHASE 2 15 251 60 900 600 9,000
TOTAL 24 418 1,440 14,400
PHASE PROVINCES LOCALITIESPROVIDERS HOUSEHOLDS
38Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
Other eligible Children
- Questions about the type, quality and satisfaction of services received andname of the health care agent providing care
Mother
Last Child Born (aged between 1 and 12
months)
Managers
Doctors
Exit Poll
- Information on the newly-born child shall be provided by the mother or personin charge of nursing the child
Hous
ehol
d Su
rvey
- Household usual socio-demographic indicators. History of pregnancies andchildbirths
Spec
ific
Med
ical
Rec
ords
- Questions related to three-four hypothetical visits to learn about good practice protocols.
Medical records recovery at the PHC Facilities
- Measuring encephalic perimeter - Measuring height
- Measuring weight
Specific measures taken in the field (to the mother
and the latest born child)
- Weight and height - Contraceptive methods - Last visit of the child, PHCC he attended, name of the health agent
- Anemia test (Hemo cue)
- Child's APGAR index
- General features of the center (staff, infrastructure, equipment, inputs, resources, expenditures and sources of funds)
- Demographic and Labor and professional qualifications
- Questions related to their attendance to the center - Socio-economic questions
- In PHCCs, number of consultations per type of patient (age, gender) and reason, per month during the last year.
- Reconstruction of medical care received
Serv
ice
Prov
ider
s
- Mother's aerobic capacity; contraceptive methods; practices of hygiene and healthy behavior
- Information on the latest pregnancy and childbirth- Weight and height of the mother and the child, child's APGAR index; mental
health
- Checklist all the contents of the medical records
Questionnaires contents
39Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
• The national coverage of the program in 2007 required a new strategy to capture causality
• We chose a randomized promotion at locality level
• The randomized promotion design focuses on the effect of the program on beneficiaries. For outcomes two and three (impact in providers behavior), a number of alternatives are being considered
New Strategy: Instrumental Variables
40Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
• The promotion should satisfy the following sufficient and necessary conditions to qualify as a valid instrumental variable:
• A pilot survey was implemented to verify the fullfiment of the conditions and to compute sample power analysis (oct-2007)
1. Being correlated with program enrollment2. Not being correlatedthe the error term (other features of
the population)3. Only affecting health results through Plan Nacer
interventions
Randomized Promotion Design
41Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
• We want to learn more about the design of the providers incentives mechanism and its impact in the use of Primary Health Care practices that hits in health outcomes and prevent billing opportunism
• Promoted localities follow up to enhance the quality of the Instrumental Variable
• Adequate design of moments 1 and 2 to better capture the Plan Nacer´s impact
• Diffusion of survey results and knowledge
Methodological challenges
42Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
2009 2010 2011 2012 Dec 2012
1st Phase : Randomizad promotion for pregnant women2nd Phase : Baseline
Midterm Ealuation
causality to learn about providers behaviour
Final Impact Evaluation 1st
PhaseI.E.
Plan Nacer
End of 1st
Phase
1st Phase: • Provinces fund 30% of the USD 5 per beneficiary
2nd Phase: • Improve use of practices • Monitoring use of funds
Plan Nacer and itsImpact Evaluation prospective time-line
End of 2nd
Phase
Final Impact Evaluation 2nd
Phase
DIVULGE RESULTS
43Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
44Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
A two level incentives system
NATION - PROVINCE
Relationships
PROVINCE - PROVIDER
Payment for enrollment
Payment for health outcomes
Payment for PHC practices billed
Decision of final use of funds
Principal – Agent Framework
45Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop
Coverage Rate EvolutionNE Region
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
April
- 05
Aug -
05
Dec -
05
April
- 06
Aug -
06
Dec -
06
April
- 07
Aug
-07
Dec -
07
Jan
-08
Feb-
08
Mar-0
8
April
-08
May-
08
Jun-
08
Jul-0
8
Aug -
08
Sep
- 08*
Oct-0
8*
Nov-
08*
Dec-
08*
CorrientesChacoFormosaMisionesNE
Provincial Goal